Definition

Impotence is the inability to attain or maintain an erection of the penis that is firm enough for sexual intercourse.

Causes

To initiate and maintain an erection, the penis must fill with blood. Nerve signals stimulate this engorgement. They prompt the blood vessels in the penis to expand so blood can fill it. Meanwhile, other blood vessels constrict, trapping blood inside.

The following factors can cause erectile dysfunction:

Venous Leak

If a leak in the blood vessels in the penis allows blood to escape, an erection may not be attainable, or may not last long. This can be caused by injury or disease.

Neurovascular Function

• Erection cannot be attained if nerve signals do not prompt blood vessels to expand or if blood flow to the penis is reduced.
• Nerve dysfunction can also diminish feeling in the penis resulting in impotence.
• Diabetes can interfere with nerve signals.
• There may be a complete loss of nighttime erections.
• Arteriosclerosis (hardening of the arteries) can cause reduced blood flow.
• Peripheral neuropathy, spinal cord injury, and surgery can also damage nerves.
• Many medications also cause erectile dysfunction.

Psychological Factors

The brain initiates many of the nerve signals required for a successful erection. Emotional problems may play a role in men who suddenly develop impotence.

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition.

Risk factors include:

• Age: 65 and older
• Medical conditions:
  • Diabetes
  • Arteriosclerosis (hardening of arteries)
  • Chronic kidney disease
  • Liver failure
  • Peyronie's disease (bending of the penis caused by scar tissue)
  • Endocrine disorders
  • Neurological disorders (ie, multiple sclerosis, peripheral neuropathy, stroke)
  • Hypertension
  • Psychiatric disorders (ie, anxiety, depression)
• Traumatic conditions:
  • Vascular surgery
  • Pelvic surgeries (particularly for prostate cancer )
  • Spinal cord injury
• Behaviors:
  • Alcohol use
  • Illegal drug use
  • Anabolic steroid use
  • Heavy smoking
  • Interpersonal conflicts with a sexual partner
• Medications:
  • Antihypertensives
  • Antihistamines
  • Antidepressants
  • Tranquilizers
  • Antipsychotics

Symptoms

Symptoms include:

• A less firm penis
• Fewer erections

Diagnosis

The doctor will ask about your symptoms and medical history, and perform a physical exam. Expect questions about the frequency, quality, and duration of your erections. Your answers may help determine if primarily psychological or physical factors are causing your impotence.

The doctor will examine your penis, testes, and rectum. If a physical cause is suspected, the doctor may order laboratory tests. These laboratory tests will include hormone levels such as thyroid function tests, prolactin levels, and testosterone levels.

Nocturnal Penile Tumescence Testing

This test can distinguish psychogenic impotence from those due to neurovascular causes.

Imaging

Sometimes Doppler imaging may be done to look at the blood flow and to make sure that there is no obstruction in the arteries or veins that supply the penis.

Treatment

Treatment options include:

Medications

This includes a group of medications that are known as phosphodiesterase inhibitors. Sildenafil, tadalafil, and vardenafil are some of the available ones. These are not taken in concomitant use of nitrates .Your doctor will evaluate you for any contraindications before you take these medications.

Oral Testosterone

Oral testosterone is used only for men whose impotence is caused by low testosterone levels.

Drugs Injected Into the Penis

Alprostadil may be used and is either injected into the penis or inserted into the urethra as a suppository.

Vacuum Devices

• Plastic cylinder for the penis
• Hand pump for pumping air out of the cylinder
• Elastic band for holding the erection after removal of the cylinder

Vascular Surgery

Vascular surgery repairs venous leaks and has been shown to be effective in some cases.

Penile Implants

These are semirigid, malleable, and inflatable implants that are surgically inserted into the penis.

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Sex Therapy

Sex therapy may help impotence resulting from:

• Ineffective sexual techniques
• Relationship problems
• Anxiety
• Depression

Prevention

To reduce your chance of becoming impotent:

• Take medications to manage blood pressure, diabetes, or depression.
• If medications may be the problem, ask your doctor about changing the medication or adjusting the regimen.
• Maintain a healthful lifestyle and diet.
• Do not smoke. Smoking is significantly associated with erectile dysfunction in middle-aged and older men.
• Try ongoing communication and relationship counseling to prevent or manage interpersonal conflict.

RESOURCES:

American Urological Association
http://www.auafoundation.org

UrologyHealth.org
http://www.impotence.org

CANADIAN RESOURCES

Canadian Urological Association
http://www.cua.org/

Sexualityandu.ca
http://www.sexualityandu.ca/eng/

References:

American Academy of Family Physicians website. Available at: http://www.aafp.org/online/en/home.html.

American Urological Association website. Available at: http://www.auafoundation.org.

National Institute of Diabetes and Digestive and Kidney Diseases website. Available at: http://www.niddk.nih.gov/.

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